Fixed hardcoded webroot.
[openemr.git] / templates / insurance_companies / general_edit.html
blob673394d94ae8366942cdd4816253f5b7a95ec2f3
1 <form name="insurancecompany" method="post" action="{$FORM_ACTION}" onsubmit="return top.restoreSession()">
2 <!-- it is important that the hidden form_id field be listed first, when it is called it populates any old information attached with the id, this allows for partial edits
3 if it were called last, the settings from the form would be overwritten with the old information-->
4 <input type="hidden" name="form_id" value="{$insurancecompany->id}" />
5 <table CELLSPACING="0" CELLPADDING="3">
6 <tr>
7 <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >{xl t='Name'}</td>
8 <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE" >
9 <input type="text" size="40" name="name" value="{$insurancecompany->get_name()}"/>
10 </td>
11 </tr>
12 <tr>
13 <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >{xl t='Attn'}</td>
14 <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE" >
15 <input type="text" size="40" name="attn" value="{$insurancecompany->get_attn()}"/>
16 </td>
17 </tr>
19 <tr>
20 <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >{xl t='Address'}</td>
21 <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE" >
22 <input type="text" size="40" name="address_line1" value="{$insurancecompany->address->line1}"/>
23 </td>
24 </tr>
25 <tr>
26 <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >{xl t='Address'}</td>
27 <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE" >
28 <input type="text" size="40" name="address_line2" value="{$insurancecompany->address->line2}"/>
29 </td>
30 </tr>
31 <tr>
32 <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >{xl t='City, State Zip'}</td>
33 <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE" >
34 <input type="text" size="25" name="city" value="{$insurancecompany->address->city}"/> , <input type="text" size="2" maxlength="2" name="state" value="{$insurancecompany->address->state}"/> <input type="text" size="5" name="zip" value="{$insurancecompany->address->zip}"/>
35 </td>
36 </tr>
37 <tr>
38 <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >{xl t='Phone'}</td>
39 <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE" >
40 <input TYPE="TEXT" NAME="phone" SIZE="12" VALUE="{$insurancecompany->get_phone()}"/>
41 </td>
42 </tr>
43 <tr>
44 <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >{xl t='CMS ID'}</td>
45 <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE" >
46 <input type="text" size="15" name="cms_id" value="{$insurancecompany->get_cms_id()}"/>
47 </td>
48 </tr>
49 <tr>
50 <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE">{xl t='Payer Type'}</td>
51 <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE">
52 {html_options name="freeb_type" options=$insurancecompany->freeb_type_array selected=$insurancecompany->get_freeb_type()}
53 </td>
54 </tr>
55 <!--
56 This is now deprecated use the newer x12 partner code instead
57 <tr>
58 <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE">X12 Receiver ID</td>
59 <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE">
60 <input type="text" name="x12_receiver_id" value="{$insurancecompany->get_x12_receiver_id()}" >
61 </td>
62 </tr>-->
63 <tr>
64 <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE">{xl t='Default X12 Partner'}</td>
65 <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE">
66 {html_options name="x12_default_partner_id" options=$x12_partners selected=$insurancecompany->get_x12_default_partner_id()}
67 </td>
68 </tr>
69 <tr>
70 <td><br /><input type="submit" value="{xl t='Update'}" /></td>
71 </tr>
72 </table>
73 <input type="hidden" name="id" value="{$insurancecompany->id}" />
74 <input type="hidden" name="process" value="{$PROCESS}" />
75 </form>